PB2626: THROMBOPOIETIN RECEPTOR AGONISTS FOR RESISTANT THROMBOCYTOPENIA IN PREGNANCY A CASE SERIES AND REVIEW OF LITERATURE
Authors: Gamal Sayed, Sarah Elkourashy, Dina Soliman, Naela Al Mallahi, Awni Alshurafa, Amna Gamil, Firyal Ibrahim, Mohammed Alnajjar, Shehab Mohamed
Journal: HemaSphere (2023)

Topic: 32. Platelet disorders Background: The incidence of Immune thrombocytopenia (ITP) in pregnancy ranges from 0.1 to 1/1000 pregnancies. Severe ITP (serum platelet counts less than 10,000 per microliter) constitute an even smaller subset of these patients and is challenging to manage. Aims: We report on two cases successfully treated with Thrombopoietin receptor agonists at our tertiary institution and a review of studies using TPO-RA (Thrombopoietin Receptor Agonists) in pregnancy. Methods: Our first patient was a nulliparous 28-year-old woman diagnosed with chronic ITP in 2015. Before she became pregnant, she was labelled “steroid-resistant,” and she only achieved complete remission with eltrombopag. Throughout her pregnancy.She had a caesarean section for suspected fetal compromise during the second stage of labour. We managed the same patient again in her second pregnancy. At 34 weeks, she was offered Romiplostim, to which she responded favourably. She had an uneventful caesarean section at 38 weeks due to suspected fetal compromise in the second stage of labour. Our second patient was a primigravida with a history of ITP since 2018. She was referred to our institution at eight weeks gestation after a routine checkup revealed a critical platelet count of 13,000 per microliter. She did not experience any episodes of bleeding or ecchymosis. At 24 weeks, she was started on IVIG and steroids. Despite treatment, her platelet count remained around 25,000 per microliter. The patient was offered Eltrombopag at 35 weeks of gestation, to which she responded well. She subsequently had a vaginal delivery and an uneventful postpartum period. Results: We reviewed the literature for relevant studies on TPO agonists during pregnancy. Our search yielded one observational study, the rest being case series and case reports. The earliest case report was from 2012, and the most recent was from 2022. There were a total of thirty-three studies found. The gestational weeks during which low platelet counts are reported to range from the beginning of pregnancy or even earlier to the third trimester This wide range was also demonstrated in the lone study involving 17 patients, where the range was from 1 week to 39 weeks. The median platelet count was 15,000 per microliter, and 17 patients (51%) received Eltrombopag tablets, while the remaining (49%) received Romiplostim injections. Before using TPO agonists, an average of two different medications had been tried and failed. After TPO treatment, the median platelet count was 131,000 per microliter, and the mean was 151,000 per microliter Two cases of preeclampsia, one case of premature rupture of membranes, and one case of uterine atony were the only maternal complications observed. In most cases, the outcome of the foetus or baby was satisfactory. One newborn, however, developed neonatal ITP, while another developed thrombocytosis. Three neonates developed hypoglycemia, tachyarrhythmia, and low birth weight. Summary/Conclusion: Management of resistant cases of ITP in pregnancy is mainly derived from clinical expertise and expert consensus. Moreover, the majority of experience with TPO-RA during pregnancy comes from case reports. To prepare for delivery, the transient use of Eltrombopag or Romiplostim from around 34 weeks in refractory cases of severe ITP is a reasonable option when other treatments fail. An ideal aim is to aim for a platelet count of over 80,000 per microliter. Induction of labour is appropriate in a subset of patients with severe disease. In different pregnancies, a mother’s response to medication can vary. Keywords: Thrombocytopenia, Immune thrombocytopenia (ITP)